title: Five-year results for endovascular repair of acute complicated type B aortic dissection.
abstract: BACKGROUND
  Despite a current lack of U.S. Food and Drug Administration approval for the indication, thoracic endovascular aortic repair (TEVAR) has replaced open surgical management for acute complicated type B aortic dissection due to promising short- and midterm data. However, long-term results, with a view toward durability and need for secondary procedures, are limited. As such, the objective of the present study is to report long-term outcomes of TEVAR for acute (≤ 2 weeks from symptom onset) complicated type B dissection.
  
  
  METHODS
  Between July 2005 and September 2012, 50 consecutive patients underwent TEVAR for management of acute complicated type B dissection at a single referral institution. Patient records were retrospectively reviewed from a prospectively maintained clinical database.
  
  
  RESULTS
  Indications for intervention included rupture in 10 (20%), malperfusion in 24 (48%), and/or refractory pain/impending rupture in 17 (34%). One patient (2%) had both rupture and malperfusion indications. Ten (20%) patients required one or more adjunctive procedures, in addition to TEVAR, to treat malperfusion syndromes. In-hospital and 30-day rates of death were both 0%; 30-day/in-hospital rates of stroke, permanent paraplegia/paraparesis, and new-onset dialysis were 2% (n = 1), 2% (n = 1), and 4% (n = 2), respectively. Median follow-up was 33.8 months [interquartile range, 12.3-56.6 months]. Overall survival at 5 and 7 years was 84%, with no deaths attributable to aortic pathology. Thirteen (26%) patients required a total of 17 reinterventions over the study period for type I endoleak (n = 5), metachronous aortic pathology (n = 5), persistent false lumen pressurization via distal fenestrations (n = 4), type II endoleak (n = 2), or retrograde acute type A aortic dissection (n = 1). Median time to first reintervention was 4.5 months (range, 0 days-40.3 months). Of the 17 total reinterventions, six (35%) were performed using open techniques and 11 (65%) with endovascular or hybrid methods; there was no difference in survival between patients who did or did not require reintervention.
  
  
  CONCLUSIONS
  This study confirms the excellent short-term outcomes of TEVAR for acute complicated type B dissection and demonstrates the results to be durable and sustained over long-term follow-up. Although aortic reinterventions were required in one-quarter of patients, no aortic-related deaths were observed. These data support the use of TEVAR for acute complicated type B aortic dissection but also highlight the importance of life-long aortic surveillance by an experienced aortic referral center in order to identify and treat complications of the underlying disease process and treatment, as well as new aortic pathologies, as they arise.
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Hanna
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Nicholas D
authors.initials: ND
authors.lastname: Andersen
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Asvin M
authors.initials: AM
authors.lastname: Ganapathi
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Richard L
authors.initials: RL
authors.lastname: McCann
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC. Electronic address: gchad.hughes@duke.edu.
authors.forename: G Chad
authors.initials: GC
authors.lastname: Hughes
mesh_terms: D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009657:North Carolina; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome